The Provider Reimbursement Review Board (PRRB) issued its decision on the Massachusetts Section 1115 Waiver Commonwealth Care Health Insurance Program (CCHIP) case on January 27, 2017, in favor of the hospitals. A copy of the majority PRRB decision as well as a concurring decision issued by Board members Clayton Nix and Charlotte Benson can be found HERE.
The Issue
“Whether days attributable to patients who were eligible for, and received, assistance through the Massachusetts Commonwealth Care Health Insurance Program (CCHIP), a CMS-approved § 1115 waiver, should be included in the numerator of the Medicaid fraction for the Medicare Disproportionate Share Hospital (“DSH”) adjustment calculation.” ~CMS.gov
Summary of Arguments & Notes
During the proceedings, the MAC argued:
That CCHIP is a subsidized insurance coverage benefit and that the benefit does not make a person eligible for Medicaid.
Even if the government matches the State’s CCHIP funding, it does not mean CCHIP is eligible for Medicaid or medical assistance.
The patients are not Medicaid patients.
The waiver does not make CCHIP patients eligible for inpatient hospital services.
The CCHIP patient population is not eligible for matching federal payments but only the pool of funds used to provide premium assistance is matched by XIX funds.
The hospitals disagreed with all these points above and the PRRB agreed with the hospital's arguments. The PRRB noted:
The approved expenditure authority clearly states that 1115 demonstration program expenditures, including CCHIP, are regarded as expenditures under title XIX.
The days at issue, as confirmed by testimony at the hearing, are for CCHIP patients federally funded under the waiver.
The CCHIP patients under appeal received the same core benefits as other MassHealth recipients, including inpatient hospital benefits.
The Board majority is not persuaded by the MAC’s arguments.
Decision
The days at issue (CCHIP) should be included in the Medicaid numerator in the Medicare DSH calculation and that the appeals be remanded back to NGS to recalculate the hospitals’ Medicare DSH payment for FY 2009.
What has Happened Since the PRRB Decision was Issued?
In terms of next steps, the CMS Administrator has notified the hospitals that the agency will be reviewing the decision and either reverse or affirm the decision. If the Administrator reverses the decision then the providers would then file for relief in federal district court. This should occur within the next 60 days. In terms of our best guess, we would expect that the Administrator will reverse this PRRB decision, in which case, a court action will be filed within 60 days of the Administrator’s reversal. We will keep you informed as this plays out however, please contact us if you have any questions.